What is Binge Eating?
Binge Eating is defined as eating a large amount of food within a discrete period of time along with a feeling of being out of control during the binge eating episode (Berkman, Brownley & Peat, 2015). Binge eating occurs on a spectrum and in its most severe manifestation is labelled as Binge-Eating Disorder (BED), which was introduced in the Diagnostic Statistical Manual-5 (DSM-5). Whilst meditation and mindfulness, has been shown to decrease episodes of binge eating, alongside improving self-control with regards to food (Kristeller & Wolever, 2011), clinical experience suggests that there are other significant factors, such the importance of defining binge and emotional eating, the role of weight-loss and the impact of focussing too much on food which need to be considered when employing mindfulness-based strategies. The aim of this post is not to present a broad, in-depth critical evaluation, but rather will address several points in detail, highlighting some essential factors that must be considered when utilizing mindfulness-based approaches to treat binge-eating issues.
Presently, there are a number of treatment approaches that incorporate mindfulness for BED which include, Dialectical Behavioural Therapy (DBT), Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Eating Awareness Training (MB-EAT) (Kristeller, Baer & Wolever 2006). The remainder of this assignment will explore briefly these models, followed by a critical evaluation.
Dialectical Behavioural Therapy
The rationale for using DBT is based on an affect regulation model of binge eating, which postulates that binge eating functions to reduce negative/unpleasant emotional states in individuals who find emotional regulation difficult (Wiser & Telch, 1999). The therapy emphasizes a non-judgmental approach and sustained awareness of emotional states which helps to reduce or eliminate binge eating urges (Kristeller, Baer & Wolever, 2006). The use of DBT has shown a reduction in binge eating and increased quality of life, along with an increase in emotional regulation abilities. Additionally, it has also been found that treatment effects were sustained six months later (Masson et al., 2013), with recommendations for larger studies being suggested (Chen et al., 2008).
Mindfulness Based Cognitive Therapy
MBCT for binge eating disorder has been explored by Baer, Fischer & Huss (2005). Whilst it was originally designed for depressive relapse, the strategies employed by MBCT are not exclusive to depression, and therefore have been adapted to treat binge-eating disorder (Kristeller, Baer & Quillian-Wolever, 2006). The intervention includes a number of mindfulness practices designed to aid the cultivation of non-judgment and non-reactive observations, as well as acceptance of bodily sensations. A better connection to hunger and satiety is also an expected outcome. In a case study conducted by Baer et al. (2005), MBCT was shown to eradicate binge eating, along with a reduction in weight, eating and shape concerns.
Acceptance and Commitment Therapy
ACT suggests that disordered eating may be related to avoiding negative internal experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). The therapy places focus on non-judgemental acceptance of feelings and thoughts whilst changing behaviour towards valued goals and direction (Hayes, Strosahl, & Wilson, 1999). This approach also emphasizes the role of good nutrition which is considered to provide energy for the movement towards valued goals (Kristeller, Baer & Quillian-Wolever, 2006). Whilst it has been suggested that further research in the field of ACT is necessary, it has also been stated that ACT could be a viable treatment option for individuals with eating disorders (Juarascio, Shaw, Forman, et al., 2013).
Mindfulness-Based Eating Awareness Training
MB-EAT was developed by combining elements of Mindfulness-Based Stress Reduction (MBSR) with Cognitive Behavioural Therapy (CBT) with the addition of guided eating meditations. Within this framework, binge eating is viewed as a symptom of disturbances of affect regulation, cognitive and behavioural dysregulation and physiological dysregulation. It is thought that the mindfulness meditation will enable individuals to both become aware of, and break free from negative behaviour patterns. The programme also places emphasis on mindful eating by tuning into hunger and satiety signals (Kristeller, 2003). MB-EAT consists of ten core sessions with two follow-up sessions (Kristeller, 2015). In terms of empirical outcomes, MB-EAT has been shown to reduce or eliminate binge eating, along with decreased depression and anxiety (Kristeller & Hallett, 1999; Kristeller, Wolever & Sheets, 2014).
Recent material added to the programme incorporates the 500 calorie challenge which is designed to aid weight loss by cutting out 500 calories per day. The results seem to be encouraging with participant results ranging from no further weight gain to losing up to 25lbs of weight (Kristeller, 2015). Whilst the aim of this paper is to evaluate mindfulness-based approaches in the treatment of binge eating, the topic of obesity and weight-loss in relation to binge eating does need to be considered. Firstly, because it is a consideration in some mindfulness-based approaches for binge eating research papers (Telch, Agras & Linehan, 2001; Katterman, Kleinman, Hood, Nackers & Corsica, 2014; Kristeller et al., 2014; Caldwell, Baime & Wolever, 2012); secondly, because mindfulness-based approaches are being marketed as effective weight-loss tools (McKenna, 2005; Spinardi, 2013; Wolever & Reardon, 2016), and thirdly because not only can it be a consequence of binge-eating, but also in some cases a trigger too, the notion being that an unhealthy body-image and preoccupation with weight-loss leads to dieting, which often leads to binge-eating behaviour (Foxen-Duke, 2015).
The approaches discussed above do show similarities in the sense that they all focus in some way on developing a heightened sense of awareness, a non-judgemental stance, emotional regulation and self-compassion. Whilst these mindfulness- based protocols are clearly showing effectiveness in the treatment of binge eating, my personal experience from both having recovered from severe binge-eating disorder, as well as treating a large number of individuals with binge/emotional eating issues, has been somewhat different. Without doubt, these approaches provide a valuable contribution to treatment plans, but there are some important factors that need to be taken into consideration.
The mindfulness-based approaches discussed above do not distinguish clearly the difference between binge and emotional eating, but rather in some cases, claim that binge eating is the result of trying to reduce negative/unpleasant experiences (Wiser & Telch, 1999; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). This in itself is an issue, because what is not so widely recognised is that binge and emotional eating commonly occur for different reasons, and hence require different interventions. The definition for emotional eating is similar to the definition adopted by some mindfulness approaches above, and has been described as eating to soothe an emotional response (Foxen-Duke, 2017). Binge eating however, has been described as a reactive disorder, propelled mainly by physical and psychological restriction (Hansen, 2014; Kerr, 2017). The source of this restriction in a vast majority of cases is a negative body-image (Duke, 2015) along with dieting to control weight (Field, Austin, Taylor et al., 2003; Polivy & Herman, 1985). It is also worth noting that most people experience a combination in varying degrees of binge and emotional eating issues, which requires careful consideration when designing a treatment plan.
The absence of a definition between binge and emotional eating presents two challenges with some mindfulness-based approaches. Firstly, given that weight control plays a major factor in the onset of binge-eating (Foxen-Duke, 2015), encouraging weight loss as part of treatment may exacerbate the problem. For example, the 500 calorie challenge introduced by the MB-EAT programme will in some cases propel individuals back into the cycle of binge eating over a period of time. Personal clinical experience has often highlighted that whilst mindfulness itself is a good tool to both help individuals re-establish connection with their internal hunger and satiety signals, as well as deal with uncomfortable emotions, focus on losing weight will overtime propel the desire for a thinner body, which will again lead to restriction (sometimes without the client recognising it), resulting in the onset of binge-eating. My own personal experience with binge-eating disorder was reflective of this example. I struggled with mindfulness and weight-loss for ten years, before I finally understood that using mindfulness as a strategy to lose weight was actually a trigger for my binge-eating. I would argue that in some cases individuals will never completely be able to break free from binge-eating as long as they focus on weight loss as a goal. This is also supported by Tribole & Resch (2012) who state clam that focus on weight loss will impact decisions about eating and sabotage the process.
Additionally, weight-loss is a complex issue affecting everyone differently. The set-point weight theory claims that there is a healthy weight that the body naturally aims for, a point at which it functions optimally. The body then works tirelessly to ensure that it remains in alignment with that weight. However, if we keep on interfering with the set-point via physical/psychological restriction, the body may eventually adopt a higher set-point to protect against future restrictive eating. Rather than pursuing weight-loss, it has been recommended that individuals focus on health affirming behaviours, such as eating well and exercising regularly – without placing focus on weight loss (Bacon, 2008). Personal clinical experience suggests that this strategy results in individuals naturally moving towards the weight that is both natural and optimum for them. This is also supported by Kerr (2017) who highlights that individuals who are overweight will often begin to lose weight once they focus on addressing seven crucial factors, which amongst others include eliminating restrictive eating, nutritional deficiencies and emotional health.
Secondly, a very common issue that I encounter regularly is individuals unknowingly turning the mindfulness eating principles into another diet. Eating only when hungry, stopping when satisfied and savouring food becomes the “new set of rules” for losing weight. Foxen-Duke (2018) describes this as the hunger-and-fullness diet, which is a perversion of intuitive/mindfulness eating, driven by diet mentality and the need to lose weight. Many a time this will act as psychological (and sometimes physical) restriction consequently resulting in binge eating. Whilst reconnecting with internal hunger and satiety cues is a sound strategy, timing is of utmost importance. Before these instructions are explored, an individual first needs to address what restriction means for them and how it is manifesting. Quite often a regular feeding schedule is needed, where individuals learn to break away from diet mentality and work towards eating nutritiously, regularly and enough. (Kerr, 2017; El-Shafie, 2018). A study conducted during world war 2 in which 32 healthy men were placed on a semi-starvation diet of 1,570 calories daily highlight the consequences of food restriction. During the re-feeding period the men experienced intense and insatiable hunger, with weekend binges resulting in 8,000-10,000 calories. It took a majority of the men to an average of five months to normalise their eating (Keys, Brozek, Henschel, Mickelson & Taylor, 1950). This is similar to what many of my clients have experienced, with dieting being akin to the semi-starvation period and binge-eating the consequence, but quite often this remains a cycle. As the client begins their journey of restriction-free eating, they often go through a period eating more than usual as their physiology and psychology begins to heal. Connecting with hunger and satiety signals becomes much easier once they have passed through this phase. Dietician El-Shafie (2018) shares this view, stating that individuals with a history of binge-eating are not always able to tune into hunger and satiety until they have re-established a regular eating pattern, with specific focus on stabilizing blood sugar and without any restriction in the background. She claims that introducing the exploration of hunger and satiety too early will in many cases exacerbate the issue.
Another personal issue that I have encountered with the mindfulness approach that can often trigger a restrictive mind-set amongst individuals struggling with binge-eating, is too much focus on the experience of eating. Boudette (2010) for example, introduces Kristeller’s eating like a gourmet exercise, in which the client is instructed to savour their food, rating the degree of pleasure. For some individuals, including myself this is counter-productive, because rather than putting the experience of eating under a microscope, what I needed to learn was to be “normal” around food. Fain (2016) captures this well, when she quotes someone commenting on Kristeller’s book, The Joy of Half a Cookie:
Yes, let’s add more dietary neurosis to the babel of nutritional advice. How about this: eat the whole cookie. Have two, even. Just eat cookies less often, and eat nutritious food as the rule rather than the exception (Fain, 2016, para. 5).
The other point for consideration with eating a cookie mindfully is the impact that it has on blood sugar. Whilst I understand that the point of the exercise is to practice mindfulness when eating, El-Shafie (2018) raises a crucial point when she mentions stabilising blood sugar. Again, introducing this exercise whilst the person still has an erratic eating pattern may further add to the issue.
From the evidence presented, it can be concluded that mindfulness-based approaches are without doubt showing effectiveness in the treatment of binge-eating. However, practical experience has shown that there are some important factors that need consideration to improve effectiveness of treatment. One of the major points is one of definition, with the main issue being that current mindfulness-based studies do not distinguish between binge and emotional eating, both of which require different interventions. Additionally, these manifestations often coincide, but in varying degrees. Bearing this in mind, I would question to what extent and in what roughly what proportion, the participants in the mindfulness-based studies were displaying these two different manifestations, because this will impact the way in which we interpret the studies, and may lead to a more refined conclusion about the circumstances in which mindfulness practice is most effective. For example, if many of the participants were in fact emotional eaters as opposed to binge-eaters, then perhaps we may conclude that mindfulness-based approaches show better efficacy with emotional eaters. This will then help us to better place the mindfulness based strategies within a treatment plan.
The mindfulness-based approaches are excellent tools to develop heightened awareness, emotional regulation, non-judgement and compassion with regard to One’s relationship with food. However, the approaches also significantly lack the framework to be able to deal with restriction-based binge-eating, and in some cases, may exacerbate the condition.
My personal approach to using mindfulness as part of a treatment plan, would be to set it in more of a tighter context, in which an individual’s reasons for bingeing would first be explored thoroughly to ensure that mindfulness is being used in the safest manner possible. I would also remove weight-loss as a goal and place more emphasis on building and nurturing a healthy mind-set in terms of food and body-image. Binge-eating is complex issue and requires a gently tailored, multi-faceted approach in order be treated more effectively.
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